Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | E4241 | CA |
Y | 213ES0000X | Sports Medicine | E4241 | CA |
NPI | 1487765863 |
---|---|
Provider Name | Thana Krisdakumtorn |
First Address | Los Altos, CA 94022-1408 |
Second Address | Palo Alto, CA 94301-2302 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 04/03/2020 |